Unsolved mystery goes down in history

  • Posted on: May 19, 2022

Maintaining silence over the facts of a procedure / intervention and not presenting relevant medical records in a court case could be inferred as medical negligence, as these doctors found out in this case.

The patient underwent laparoscopic surgery for hernia problem. For some unknown reasons the procedure went on for more than five hours. His family was shocked to know that he had slipped into coma when brought out of the OT. The doctors didn’t give any convincing reasons.

For some unknown reasons, patient was again taken back to the OT.

A neurosurgeon was consulted after five days. He opined that patient’s brain was probably ‘damaged’ during surgery and advised that he should be put on ventilator.

The patient was taken to a higher centre where he remained unconscious – in coma – for over a month. He eventually died due to unexplained and unknown complications.

Knowing the cause of death is perhaps very crucial for patient’s family to get an emotional closure. In search of answers, they approached the Consumer Commission, as the doctors did little to share the facts with them.

The doctors stated in defence that vein which connects brain and neck was pressurised as patient changed sleeping position, resulting in loss of oxygen flow to his brain. It was further stated that the neurosurgeon also agreed that phrenic encephalopathy due to possible unstable C.V. junctional problem was created. There was no negligence on our part, concluded the doctors.

The Commission did not accept their submission, and held the doctors negligent. The bench’s detailed observations and reasons are reproduced below:

“In absence of proper explanation by the doctors, it is difficult to presume why the patient was taken to OT for second time. Moreover, they have not submitted any proof, not even treatment papers. It is negligence on part of the hospital and doctors for not doing so”.

“It cannot be denied that excess amount of anaesthesia and lack of oxygen were the reasons for patient slipping into coma, if anaesthesia was properly administered then the patient should have been conscious. The doctors have claimed that C.V. junction problem was created and hence the brain did not get any oxygen. If we consider the medical literature, brain cells get damaged if it does not receive oxygen even for a minute. The doctors have not answered in their reply after how much time oxygen was given to the patient”.

“Furthermore the patient was in OT for more than five hours. It is not acceptable that laparoscopic hernia operation can consume so much time. I would like to come to conclusion that something other than the said situation has happened which is not explained. There is no admissible evidence, medical papers were also not brought on record by the doctors”.

Only the doctors may know what actually transpired in the OT. One thing is apparent though – such instances could be harmful to the healthcare’s ecosystem in long run

Source:Order pronounced by Gujarat State Consumer Disputes Redressal Commission on 7th December, 2021.